Post-Operative Chapters 21 and 22
Dr. Vasanthi Vidyasagaran*
Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India
*Correspondence: Vasanthi.vidyasagaran@gmail.com
POST-OPERATIVE Chapter 21
Respiratory Obstruction Due to Adenoid Pack
An eight-year-old boy, weighing 30 kilograms was posted for Adeno-tonsillectomy. On examination, his lungs were clear, airway showed Mallampati Class 2, and pulse rate of 108 beats/min. All his investigations were within normal limits. He was taken up for surgery under general anaesthesia. He was pre-medicated with injection Glycopyrrolate 0.1 mg, half an hour before surgery. Aspiration prophylaxis (Ranitidine 25 mg + Ondansetron 2mg) was given.
He was pre-oxygenated for 3 minutes and induced with Thiopentone 150 mg and Fentanyl 50 µg. For intubation, 20 mg Atracurium was used. Sevoflurane 2%, Oxygen and Nitrous Oxide mixture was used for maintenance. Standard monitoring was done.
The surgery lasted 35 to 40 minutes and no more relaxants were given. At the end of procedure, he was reversed with Neostigmine 1 mg and Glycopyrrolate 0.1 mg. After ensuring adequate breathing, he was extubated in a deep plane. There was no post nasal bleeding and the gauze count was mentioned to be correct.
Post extubation, patient started to desaturate. Respiration was noisy and there was in-drawing of the ribs. Laryngospasm was suspected and intravenous hydrocortisone 50 mgs was given. CPAP was attempted, but did not relieve the obstruction. Saturation dropped to 90%. It was impossible to mask ventilate and there was unexpected tightness of the bag. The child was still quite well sedated. He was re-intubated using 50 mg Suxamethonium. The bag compliance improved and saturation went up to 100%. Nasal endoscopy did not reveal anything abnormal.
The boy began to come out of the effect of Suxamethonium, and at this point laryngoscopy revealed a blood soaked adenoid pack coming into the oral cavity which was removed. The reason for upper airway obstruction came into light. The child recovered well without further complications.
Discussion
Here was a situation of upper airway obstruction due to adenoid gauze pack left behind at the end of surgery. A wrong gauze count misled the team. Although the anaesthesiologist had checked all parameters prior to extubation in deep plane, this was not visible during laryngoscopy at extubation.
Such incidents happen even during third molar tooth extractions, where the throat pack is removed, but the gauze is often left behind.
Laryngospasm may be the most common cause of post extubation problems, but other causes including iatrogenic, must be ruled out, without any delay.
Points to Ponder
Is extubation under deep plane of anaesthesia, worth it and safe? Particularly in a child, this can be very tricky.
How deep a plane is safe for extubation? This may be learnt as a special skill over years of experience, however it remains controversial. Extubation when the patient is deep risks aspiration and loss of airway control. Light plane may risk spasm.
Extubation in the deep plane can be considered in surgeries not involving the airway. In this particular incident, the child could have easily aspirated the soaked gauze. It is important not to blindly trust the count especially if it is involving the airway. It is vital for the anaesthetist to check for themselves by direct laryngoscopy.
Extubation following laryngoscopy is the preferred method in all head and neck surgeries. The key principle in the management of all post-extubation airway problems is immediate and effective oxygenation.
Awake extubation is always the safe method of tracheal extubation, especially in a child having upper airway surgery, and I would recommend it. However, more experienced paediatric anaesthetists may prefer to extubate in deep planes.
The debate regarding deep versus awake extubation in paediatrics continues.
Stridor and Stertor: Differentiation is important to identify the level of obstruction.
Stridor is an abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, or trachea. Inspiratory stridor suggests a laryngeal obstruction, expiratory stridor implies tracheobronchial obstruction and a biphasic stridor suggests a subglottic or glottis anomaly.
Stertor, on the other hand is a lower-pitched, snoring-type sound generated at the level of the nasopharynx, oropharynx, and, occasionally, supraglottis.
References
- Swati Karmarkar, Seema Varshney; Tracheal extubation. Continuing Education in Anaesthesia, Critical Care & Pain | Volume 8 Number 6 2008
- Peterson GN, et al., Management of the difficult airway: a closed claims analysis. Anesthesiology2005; 103:33-9.
- Baijal RG, Bidani SA, Minard CG, Watcha MF. Perioperative respiratory complications following awake and deep extubation in children undergoing adenotonsillectomy. Paediatr Anaesth. 2015 Apr; 25(4):392-9.
- Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difcult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 318–340
POST-OPERATIVE Chapter 22
Sickle Cell Anaemia – A Surprise in the Immediate Post-operative Period
A 30-year-old primiparous woman, weighing 74 kg was diagnosed with pre-eclampsia. She was on treatment with tablet Labetalol 20 mg twice daily and was posted for an elective caesarean section at 38 weeks gestation.
During preoperative evaluation, she was found to have sickle cell disease. Her Hb was 10 gm%, PCV=31%, platelets=1.5 lakh/cu mm, renal, liver functions and coagulation profile were normal.
Following an unanticipated episode of convulsions at home, she had to be taken up for an emergency caesarean section. She recovered from convulsions without any medications. She was brought to the hospital with severe head ache. On admission, she was conscious, her BP was 180/120 mm Hg, PR=110 – regular, respiratory rate=20 breaths/minute. She had bilateral pedal oedema.
She was taken up for an emergency LSCS. As there was no time for further investigations and there was foetal distress, a bedside bleeding and clotting time was performed and found to be normal. Blood grouping and cross matching was done and adequate blood products were made available.
The main concern was whether to choose general or regional anaesthesia. She was a patient with a full stomach, (had solids just before coming to the hospital) airway assessment was anticipated difficult airway with MPC III and protruding maxilla, with limited mouth opening. Spine was normal. Spinal anaesthesia deemed appropriate for this patient. One dose of nifedipine 10mg was given with a sip of water. 1.8 ml of 0.5% Bupivacaine was administered using a 26G needle in the L3-L4 space. The level of block was T6. Usual monitoring was performed and supplemental oxygen was administered via face mask. The surgery was performed uneventfully. Patient was shifted to the post-operative ward.
10 hours later, there was a sudden fall in blood pressure, the patient was getting very anxious and hyperventilating. BP was 80/40. Patient was suspected to have an intra-abdominal haemorrhage and PPH. She was shifted to OT for an emergency laparotomy.
General anaesthesia using Ketamine 50 mg, Fentanyl 100 mcg, and Succinylcholine was administered. Patient was intubated with difficulty using a size 6.5 cuffed oral ETT. Anaesthesia maintained with Oxygen/Nitrous Oxide and 1% Sevoflurane. On opening the abdomen, there was a haemo-peritoneum of 2 litres, but the cause of haemoperitonium was not PPH, but a ruptured spleen! Splenectomy was done without any delay. After initial load of 1 litre of crystalloid, blood transfusion was commenced. She received 6 units packed cells, 4 units FFP and 2 units of platelets without any delay, since she was a case of sickle cell anaemia and the blood products were made available for the caesarean section. Haemodynamics were maintained with inotropic support in addition to volume support.
Early and timely transfusion of blood and blood products as an adjunct to appropriate anaesthetic and surgical management helped stabilise this patient. She was then shifted to PACU on ventilator and inotropic support. She was extubated after 48 hours when she was off inotropes, adequate respiratory function and renal function ensured. Broad spectrum antibiotic cover was provided to prevent sepsis.
Discussion
Sickle cell disease (SCD) is uncommon in the female patient as it is an autosomal recessive disease. Patients with SCD are known to have episodes of crisis triggered by dehydration, pain, and cold temperatures. They should preferably be taken up for elective procedures after investigations and adequate optimisation.
The incidence of PIH is high in sickle cell disease, and low dose aspirin is usually prescribed. Low molecular weight Heparin is advised both pre-and postoperatively to prevent thrombotic complications like acute stroke. Plan of anaesthesia should take into consideration the coagulation status, hydration, anaemia, temperature, and post-operative pain relief, thus avoiding a crisis. Routine prophylactic transfusions are not recommended.
Avoid NSAIDs for pain relief. Among narcotics, Pethidine should be avoided since the metabolite Norpethidine can accumulate and cause seizures.
Splenomegaly in SCD – Splenic enlargement in SCD patients usually occurs in the first decade of life. Later on, they undergo auto splenectomy due to recurrent splenic infarcts and decline in splenic function. However, this is not always the case, enlarged spleen may be noted in older patients with SCD. Immune function will be reduced with reduced splenic function.
Life threatening features of SCD that an anaesthetist may have to face are pain crises, severe sepsis, severe anaemia, acute chest syndrome including pulmonary embolism, splenic sequestration, liver congestion, and aseptic bone necrosis and infarcts.
The question of splenectomy arises when there is strong evidence of life-threatening episodes of acute splenic sequestration, (which cannot be predicted), or sustained hypersplenism which may result in severe anaemia.
It is postulated that factors such as stress, surgery, and pain may act as trigger factors and cause rapid sequestration of blood in spleen, and the vasculature gets obstructed. This causes rapid splenomegaly, requiring emergency intervention as the patient will be in a state of shock. Rapid transfusion of blood and blood products is the only treatment that can save the patient. This is usually a self-resolving crisis, and responds to supportive management and blood transfusion.
However, if there has been a splenic rupture as seen in this patient splenectomy must be done without any delay, taking all precautions to prevent sepsis following splenectomy.
References
- Valentine Brousse, Pierre Buffet and David Rees. British Journal of Haematology. The spleen and sickle cell disease: the sick (led) spleen. 2014
- Airede, A.I. (1992) acute splenic sequestration in a five-week-old infant with sickle cell disease. Journal of Pediatrics, 120, 160.
- Sarika Subhash Ingle and Pravin Ubale. Anesthetic management of a patient with sickle cell disease for common bile duct exploration, J Anaesthesiol Clin Pharmacol. 2011 Oct- Dec; 27(4): 547–549.
- Rajab KE, Skerman JH. Sickle cell disease in pregnancy. Obstetric and anesthetic management perspectives. Saudi Med J. 2004 Mar; 25(3):265-76.
- Indu Bala, Neeru Sahni, and Sanwar Mal Mitharwal. Anaesthetic challenges in a child with sickle-cell disease and congenital heart block. Indian J Anaesth. 2016 Apr; 60(4): 294–295.
- Sickle Cell Disease – Kids Health, kidshealth.org/en/teens/sickle-cell-anemia.html.
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- Modification of Management Strategies, And Innovations, During SARS Cov2 Pandemic Improved the Quality, Criticality and Outcomes in In-Patients “Rising to the occasion”, the mantra for success in the COVID -19 pandemic
- Time in Range (TIR) In Diabetes: A Concept of Control of Glycemia, Whose Time Has Come
- Kauvery Heart Failure Registry- A Concept
- Shorter Course of Remdesivir In Moderate Covid-19 is as Efficacious as Compared to Standard Regime: An Observational Study
- CASE REPORT
- Lymphoepithelial Carcinoma: A Case Report of a Rare Tumour of The Vocal Cord
- Diabetic Keto Acidosis (DKA), Associated with Failed Thrombolysis with Streptokinase in Acute Myocardial Infarction
- EARNING FROM EXPERIENCE – CHAPTERS 1 AND 2
- The Consultation Room
- Journal scan
- Recommended Reading
- DIAGNOSTIC IMAGE
- Notes to Nocturne
- Editorial
- Kauverian eMedical Journal
- Caring for nobody’s baby
- Special Report
- Research Article
- The curious case of a migrating needle on the chest wall
- Foreign body: A boon at times
- Cardiorenal Syndrome
- What My Grandmother Knew About Dying
- Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022
- Letter to the Editor
- Clinical outcomes of Coronary Artery Disease in Octogenarians
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 11 and 12
- The Consultation Room
- Journal Scan
- Recommended Reading
- colours
- Editorial
- Author Instruction
- Ultrashort Case Report
- Cochlear Implantation: Expanding candidacy and Cost Effectiveness
- Spontaneous Pneumomediastinum in COVID 19 – Tertiary Care Centre Experience in South India
- Amoxycillin Induced Anaphylactic Shock: A Case Report
- An Unusual Cause of Seizures: A Case Report
- Case Report
- Educational Strategies to Promote Clinical Diagnostic Reasoning
- Rheumatic Rarities
- Types of sampling methods in statistics
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 21 and 22
- The Consultation Room
- Journal Scan
- Recommended Readings
- Editorial
- Author Instruction
- Journal Scan
- Myeloma
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Prophylactic orthopaedic surgery
- Subclavian steal: An interesting imaging scenario
- Spondylo-epi-metaphyseal dysplasia (SEMD)
- The bleeding windpipe
- Learning from Experience – Intra Operative, Chapters 23 and 24
- The Consultation Room
- Diagnostic Image
- Recommended Readings
- Editorial
- Editorial Board
- Physician, Protect thyself
- Foetal Medicine, the Future is here!
- Japanese Encephalitis: A common menace
- Carpometacarpal dislocation with impending compartment syndrome
- Heterotopic pregnancy
- Femoral Trochantric and Proximal Humerus Fracture, from Diagnosis to Rehabilitation
- My Father’s Heart Block
- EPS page
- CRT CSP Cases
- Journal scan
- Learning from Experience – Intra Operative, Chapters 25 and 26
- The Consultation Room
- Recommended Readings
- Editorial
- Editorial Board
- Multiple Sclerosis: An overview
- A flower born to blush unseen
- Guest Editorial
- Radio-frequency ablation as an effective treatment strategy in a case of VT storm post STEMI
- Lymphatic malformation of tongue
- Bilateral anterior shoulder dislocation in epilepsy: A case report and review of literature
- An unusual cause of Stridor
- Monoclonal Antibodies (mAbs) – the magic bullets: A review of therapeutic applications and its future perspectives
- Write the Talk
- Press release and Comments
- Probability Distribution of Bernoulli Trials
- Journal Scan
- Recommended Readings
- poem-v4i4
- Editorial
- Editorial Board
- Research
- Research
- Lambda-cyhalothrin and pyrethrin poisoning: A case report
- Good Enough
- The Monoclonal antibodies (mAbs): the beginning
- Comprehensive trauma course 2022: Trauma Management & Kauvery
- Comprehensive trauma course 2022: Introduction to Comprehensive trauma course
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 27 and 28
- The Consultation Room
- Recommended Readings
- Poem
- Editorial
- The Brave New World of Anaesthesia
- Anesthetic considerations in Wilson’s disease for fess: A case report
- The painful story behind modern anaesthesia
- Anesthesia considerations for Ankyslosing Spondylitis
- Total intravenous anaesthesia: An overview
- Risk stratification for cardiac patients coming for non-cardiac surgeries
- The Anaesthesiologist’s role in fluoroscopic guided epidural steroid injections for low back pain
- Awake Craniotomy
- Malpositioned central venous catheter: Step wise approach to avoid, identify and manage
- Benefits outweighing risk: Neuraxial anaesthesia in a patient with Spina Bifida with operated Meningomyelocele
- Pain free CABG: newer horizon of minimally invasive cardiothoracic surgery a walk through anaesthesiologist perspective
- Stellate Ganglion Block: A bridge to cervical sympathectomy in refractory Long QT Syndrome
- Venous Malformation in Upper Airway – Anesthetic Challenges and Management: A Case Report
- Editorial
- USG guided peripheral nerve block in surgery for hernia
- Anaesthesia and morbid obesity: A systematic review
- Patient-Controlled Analgesia
- Parapharyngeal abscess of face and neck: Anesthetic management
- 3D TEE, a boon for the diagnosis of Left Atrial Appendage thrombus!
- Anaesthetic management of difficult airway due to retropharyngeal abscess and cervical spondylosis
- Expect the unexpected – Breach in continuous nerve block catheter
- Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache
- Potassium permanganate poisoning and airway oedema
- Angioedema following anti-snake venom administration
- Editorial
- Editorial Board
- Ra Fx ablation of Atrioventricular nodal reciprocating tachycardia
- Pace and Ablate Strategy: Conduction system pacing with AV junction ablation for drug refractory atrial arrhythmia – A novel approach
- Why Cardiac Resynchronization Therapy (CRT) For complete heart block? A case discussion
- Pacemakers and Bradyarrhythmias in Diabetic Mellitus
- Outcomes of Total Knee Arthroplasty in patients aged 70 years and above
- An approach to CBC for practitioners
- Acute cerebral sinus venous thrombosis with different presentations and different outcomes: A case series
- Diet and nutritional care for DDLT: A case study
- Vaccine for Dengue (Dengvaxia CYD-TDV)
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 31 and 32
- Recommended Readings
- காவிரித்தாய்
- ATLAS OF HAEMATOLOGY AND HEMATOONCOLOGY
- Editorial
- Editorial Board
- Case reports and Case series:
- Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia
- Treatment approach for extensively Drug-Resistant Tuberculosis (XDR-TB)
- Modified Lichtenstein mesh repair, for a patient of Coronary Artery Disease, Heart Failure and with Implanted Cardioverter- Defibrillator
- Fever-induced Brugada Syndrome
- Pulmonary Thrombo Embolism: When to Thrombolyse?
- Ultra-Short Case Report
- Learning from the failure of Nebacumab
- Journal scan
- Learning From Experience Intra Operative Chapters 29 and 30
- Recommended Readings
- Poem
- Editorial
- Editorial Board
- Heart transplantation: Life beyond the end of life
- Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal
- Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy
- Proximie: Patient safety in surgery – the urgent need for reform
- Analysis of femoral neck fracture in octogenarians and its management
- Adult Immunisation in Clinical Practice: A Neglected Life Saver
- “Icing” The Eyes
- Doppler vascular mapping in Arterio Venous Fistula (AVF)
- Cosmesis and cure: Radiotherapy in basal cell carcinoma of the dorsum of nose – A case report
- Pulmonary Hypertension and Portal Hypertension
- Comprehensive review of Drug-Induced Cardiotoxicity
- Statistics – Data Collection – Case Study Method
- Atlas of Haematology and Hematooncology
- PRE-OPERATIVE Chapters 1 and 2 – Learning from Experience
- Chapter 2. Uncertainties in medicine in spite of advances
- No Splendid Child
- Editorial
- Editorial Board
- A Young Girl Lost in the Storm
- ECMO as a bridge to Transplant: A case report
- Renal anemia – from bench to bedside
- Mission Possible
- New kids on the block – Update on diabetic nephropathy therapy
- Infections – Trade off in Transplants
- To Give Or Not to Give – Primer on Bicarbonate Therapy
- Sialendoscopy: Shifting paradigms in treatment of salivary gland disease
- Gait imbalance in a senior due to Chronic Immune Sensory Polyneuropathy (CISP)
- Statistics – Mcnemar Test
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE Chapters 3 and 4 – Learning from Experience
- Changing trends a challenge to the already trained
- Journal scan
- Recommended Readings
- EDITORIAL
- EDITORIAL BOARD
- PREGNANCY POST-RENAL TRANSPLANT
- BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION
- REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY
- THE AMBUSH A TEAM APPROACH
- ENDOSCOPIC TRANS-SPHENOID APPROACH FOR PITUITARY ADENOMA EXCISION
- A STUDY ON PRESENTATION AND OUTCOME OF BULL GORE INJURIES IN A GROUP OF TERTIARY CARE HOSPITALS
- A CASE OF INTERNUCLEAR OPHTHALMOPARESIS AS THE FIRST MANIFESTATION OF MULTIPLE SCLEROSIS
- GRANULOMATOSIS WITH POLYANGITIS AND LUNG INVOLVMENT (WEGENER’S DISEASE)
- RITUXIMAB (RITUXAN, MABTHERA) IN THE TREATMENT OF B-CELL NON-HODGKIN’S LYMPHOMA
- STATISTICAL SIGNIFICANCE
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- Chapter 4: Diagnostic process often reversed
- Journal scan: A review of 25 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- ஆரோக்கியம் நம் கையில்
- வெற்றியின் பாதை
- Editorial
- Editorial Board
- Prevalence of vitamin D deficiency in a multi-speciality hospital orthopaedic outpatient clinic
- Esomeprazole induced Hypoglycemia
- Dynamic external fixator for unstable intra articular fractures of Proximal Interphalangeal Joint (PIP): “Suzuki” frame
- How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide, Springer Nature, 2022
- WINTNCON 2022 – Scientific Program
- Pulmonary Thrombo Embolism: A state of the art review
- Role of Artificial Intelligence in improving EHR/EMR and Medical Coding and billing
- Monoclonal Antibodies: Edrecolomab and Abciximab
- Atlas of haematology and hematooncology
- Journal scan
- Learning from Experience – Intra Operative, Chapters 31 and 32
- What doctors must learn: Doctor, look beyond science
- Recommended Readings
- I Whisper Secrets In My Ear
- EDITORIAL
- Instructions for Authors
- Mismatched Haploidentical Bone Marrow Transplantation in a 10-year-old boy with relapsed refractory acute lymphoblastic leukemia, at Trichy
- ST-Segment Elevation is not always Myocardial Infarction
- Acyanotic Congenital Heart Disease, repaired, evolves into a Cyanotic Congenital Heart Disease and presents with an atrial tachycardia
- Family medicine – caring for you for the whole of your life. A Lost and Found Art
- The Principles and Practice of Family Medicine
- Complete Heart Block
- Sick Sinus Syndrome (SSS)
- The First Ever National Award Comes to Kauvery Hospital Chennai & Heart City for Safety and Workforce Category in IMC RBNQA Milestone Merits Recognition 2022
- Diagnostic Image
- PRE-OPERATIVE CHAPTERS 7 AND 7 – LEARNING FROM EXPERIENCE
- Chapter 5: Super-specialist – boon or bane
- Journal scan: A review of 42 recent papers of immediate clinical significance, harvested from major international journals
- RECOMMENDED READINGS
- நேரம் ஒதுக்கு
- மருத்துவரின் மகத்துவம்
- EDITORIAL
- Instructions for Authors
- Surgical Management of Covid-19 Associated Rhino-Orbito-Cerebral-Mucormycosis (Ca-Rocm) – A Single Centre Experience
- Knee Joint Preservation Surgeries
- Guest Editorial Comments
- Ventricular Septal (VSR) closure with ASD device
- Newer Calcium Debulking Angioplasty technique of Orbital Atherectomy
- An hour-long CPR to restart the heart
- VT or SVT with aberrancy?
- Pituitary Neuroendocrine Tumor (PitNET)
- VSD Device Closure
- PDA Device Closure
- Iron Deficiency Anemia, Post MVR
- Torsades de Pointes
- Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%
- Long term use of Amiodarone in Cardiac patients: A Clinical Audit
- Statistical Independent Events and Probability
- PERI-OPERATIVE Chapters 9 and 10 – Learning from Experience
- Journal scan: A review of 40 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- Kauverian Medical Journal
- First da Vinci Robotic Surgery in Carcinoma Prostate: A Case Report
- Black burden or Taylor the saviour: A case report
- Analysis of differences in Oncology practice between the United Kingdom and India
- A Case of Takayasu Arteritis
- Idiopathic Dilated Pulmonary Artery (IDPA)
- ECG Atlas
- Unusual cause of Dysphagia: A case report
- Tu Youyou: The scientist who discovered artemisinin
- Continuing Nursing Education (CNE) on Risk assessment tools, to assess vulnerable patients at Kauvery Hospital, Tennur
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 11 AND 12 – LEARNING FROM EXPERIENCE
- OLD AND NEW – MAKE THE BEST OF THE TWO
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- EDITORIAL
- INSTRUCTION TO AUTHORS
- A pregnant patient with DKA, septic shock and a lactate mystery
- Radical Thymectomy in Myasthenia Gravis through Partial Sternotomy approach: A report on three patients
- In-utero blood transfusion in two etiologically distinct anaemic fetus
- RARE CAUSE OF PULMONARY HYPERTENSION
- Acute Rheumatic fever is still an enigma
- A remarkable journey: Managing LQTS in a 43-year-old female with recurrent syncope and seizure
- An unusual case of Acute Coronary Syndrome
- Reversible cause of severe LV Dysfunction in Left Bundle Branch Block
- A case study on Rhino-Orbital-Cerebro- Mucormycosis
- Snakebite and its management
- Total Elbow arthroplasty in Post Traumatic arthritis
- Wellens Syndrome: An ECG finding not to miss!
- Dr. C.R. Rao Wins Top Statistics Award a look back at his pioneering work
- PRE-OPERATIVE Chapters 13 and 14 – Learning from Experience
- Chapter 7. Doctor-patient relationship
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- INSTRUCTION TO AUTHORS
- FROZEN ELEPHANT TRUNK (FET) PROCEDURE IN A 52 YEARS OLD CHRONIC AORTIC DISSECTION PATIENT
- DIAGNOSING AND MANAGING EISENMENGER SYNDROME IN A YOUNG MALE
- STEMI EQUIVALENT BUT STEMI!
- TEMPORARY HEAL CAN POSSIBLY KILL!
- UNDERSTANDING PUBERTY
- THE IMPORTANCE OF STATISTICS IN HEALTHCARE
- JOURNAL SCAN: A REVIEW OF 44 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 15 AND 16 – LEARNING FROM EXPERIENCE
- CHAPTER 8. DOCTOR-DOCTOR RELATIONSHIP
- EDITORIAL
- GUEST EDITORIAL
- CLINICAL AUDIT: AN INTRODUCTION
- YOUNG ACS AUDIT
- CLINICAL AUDIT: ANAESTHESIA
- CLINICAL OUTCOME IN ICU PATIENTS
- RATE OF MALIGNANCY IN INDETERMINATE OVARIAN CYST – A PROCESS AUDIT
- PATTERNS OF NEEDLE DISPOSAL AMONG INSULIN USING PATIENTS WITH DIABETES MELLITUS: AN AUDIT
- CONTINUOUS PATIENT MONITORING – LIFE SIGNS
- AGE IS JUST A NUMBER!
- SVT WITH LEFT BUNDLE BRANCH BLOCK FOLLOWING GASTRECTOMY
- COMPLEX AORTIC DISSECTION WITH MULTIFACETED CLINICAL PRESENTATIONS
- EDITORIAL
- POST-OPERATIVE SORE THROAT IN GA: A CONCERN
- NEONATAL HLH: OUR EXPERIENCE
- CLINICAL REVIEW MEET 16TH NOV 2023: CHALLENGES IN SETTING UP A NEW HSCT CENTRE IN A TIER-2 CITY IN INDIA
- CARDIAC BIOMARKERS: CLINICAL UTILITY
- HIRAYAMA DISEASE: A CLINICAL-RADIOLOGICAL REVIEW
- ECG AS A WINDOW OF OPPORTUNITY: FOR HYPERKALEMIA
- EFFECTIVENESS OF ROOD’S APPROACH BASED PAEDIATRIC OCCUPATIONAL THERAPY MANAGEMENT: ON CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS
- ELTROMBOPAG, A NOVEL THROMBOPOIETIN (TPO) RECEPTOR AGONIST: AN OVERVIEW
- HENOCH-SCHONLEIN PURPURA
- SUBMANDIBULAR GLAND SIALADENITIS SECONDARY TO SUBMANDIBULAR CALCULUS
- LEAN HOSPITALS
- STATISTICS BLACK-SCHOLES MODEL
- PERI-OPERATIVE CHAPTERS 17 AND 18 – LEARNING FROM EXPERIENCE
- CHAPTER 9. BUILDING BLOCKS OF PATIENT CARE
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- ROTATHON-SERIES OF SUCCESSFUL ROTA CASES LAST 2 MONTHS: AN AUDIT
- OUTCOMES OF AKI AUDIT IN KAUVERY
- ETIOLOGY, CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE PANCREATITIS IN KAUVERY CANTONMENT HOSPITAL (KCN), TRICHY
- USE OF BLOOD PRODUCTS AND STEROIDS IN THE MANAGEMENT OF DENGUE AT KAUVERY TRICHY HOSPITALS: A CLINICAL AUDIT
- A CLINICAL AUDIT: ON THE MANAGEMENT OF ECTOPIC PREGNANCY
- DIABETIC KETOACIDOSIS WITH HIGH ANION GAP METABOLIC ACIDOSIS
- HYPOKALEMIC PARALYSIS FROM DISTAL RENAL TUBULAR ACIDOSIS (TYPE-1)
- DELAYED PRESENTATION OF INTERMEDIATE SYNDROME IN A PATIENT WITH ORGANOPHOSPHORUS POISONING: A CASE REPORT
- SCAPULA FRACTURES: DO WE NEED TO FIX THEM?
- SPONTANEOUS CSF RHINORRHEA
- DANCING WITH DIABETES: AN UNUSUAL CASE OF CHOREA HYPERGLYCEMIA BASAL GANGLIA SYNDROME
- CONVALESCENT RASH OF DENGUE
- ECG ATLAS 2
- MI MIMICKER
- PERFORATION PERITONITIS-A CASE REPORT
- APPLICATION OF EVIDENCE BASED PRACTICE CARE FOR INDIVIDUALS WITH SPINAL CORD INJURY WITH FUNCTIONAL DIFFICULTIES: ROLE OF THE OCCUPATIONAL THERAPY PRACTICE GUIDELINES
- METHOTREXATE INDUCED MUCOSITIS AND PANCYTOPENIA: A CONSEQUENCE OF MEDICATION ERROR IN A PSORIASIS PATIENT
- POST OPERATIVE CHAPTERS 1 AND 2 – LEARNING FROM EXPERIENCE
- CHAPTER 10. NURTURING SELF
- விடாமுயற்சி வெற்றி தரும்
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- EDITORIAL BOARD
- LIMB SALVAGE IN EXTREMITY VASCULAR TRAUMA: OUR EXPERIENCE
- MANAGEMENT OF URETHRAL CATHETER RELATED PAIN IN RENAL TRANSPLANT RECIPIENTS: A CLINICAL AUDIT
- NO PAIN VEIN GAIN WITH PRILOX IN PAEDIATRIC POPULATION
- GUIDELINE-DIRECTED MEDICAL TREATMENT (GDMT) OF HEART FAILURE AT KAUVERY HOSPITALS: A CLINICAL AUDIT
- PATIENTS STORY: DIGNITY MATTERS
- PATIENTS STORY: DIGNITY MATTERS
- VIDEO PRESENTATION- CT CORONARY ANGIOGRAPHY
- DRUG INDUCED HYPERKALEMIA
- ADULT NEPHROTIC SYNDROME
- EXPLORING COMPLEX CARDIAC CASES: INSIGHTS FROM DIVERSE PRESENTATIONS IN MID-AGED WOMEN
- EFFECTIVENESS OF ACTIVITY CONFIGURATION APPROACH BASED OCCUPATIONAL THERAPY INTERVENTION FOR CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS: A CASE STUDY
- CARDIOMYOPATHY AND ITS ECHO FINDINGS
- THE STRESS TEST ON THE TREADMILL
- POST OPERATIVE CHAPTERS 3 AND 4 – LEARNING FROM EXPERIENCE
- CHAPTER 11. BALANCE IN LIFE BEYOND BANK BALANCES
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காணும் பொங்கலும் மனித மன மாற்றமும்
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- PREVALENCE OF STREPTOCOCCUS PNEUMONIAE SEROTYPES IN AND AROUND TRICHY AND ITS CLINICAL RELEVANCE
- ANAESTHETIC MANAGEMENT OF A PATIENT WITH HUGE GOITER: A CASE REPORT
- EUGLYCEMIC DIABETIC KETOACIDOSIS A RARE CAUSE FOR DELAYED EXTUBATION
- SUCCESSFUL PREGNANCY IN ASD PATIENT – COMPLICATED BY SEVERE PULMONARY ARTERIAL HYPERTENSION
- ENDOCRINE COMPLICATION OF GROWTH HORMONE SECRETING TUMOR: A CASE REPORT
- EFFICACY OF EARLY DIAGNOSIS AND DEVELOPMENT APPROACHES OF PAEDIATRIC OCCUPATIONAL THERAPY ON ACUTE DISSEMINATED ENCEPHALOMYELITIS: A CASE REPORT
- POST OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- CHAPTER 12. MILES TO GO – BEFORE TEACHING BECOMES LEARNING
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காவேரி – 25
- POEM – மண்ணில் பிறந்தது சாதிப்பதற்குத்தான்
- EDITORIAL
- EDITORIAL BOARD
- Audit Appraisal: An overview
- Intra Ventricular antibiotics: Our experience
- Transfusion Reactions: A clinical audit
- Postoperative pain management
- Rising concerns of Carbapenem resistant Enterobacteriaceae and the options available: An overview
- Ultrashort case report on VF storm in immediate Post CABG Period—‘Angry Purkinje Syndrome’
- Lynch syndrome, diagnostic challenges and management: A case report
- Bilateral posterior shoulder fracture – dislocation due to seizure, an uncommon injury: A case report
- Navigating amlodipine overdose: A multi-disciplinary approach in a 23 year old female
- Exploring the interplay between sleep patterns and behavioural characteristics in individuals with Autism Spectrum Disorder (ASD)
- POST OPERATIVE Chapters 7 and 8 – Learning from Experience
- Chapter 13. Art of communication and counselling
- Journal scan: A review of 20 recent papers of immediate clinical significance, harvested from major international journals
- மருத்துவமனையின் தேவதையே
- மருத்துவ சிந்தனை விருந்து
- Editorial
- Instructions for Authors
- Cardiac surgery in an octogenarian Indian population
- Mycotic Aortoiliac Aneurysm: A case series
- The Scorpion Block—A Sting operation
- Arterial Thoracic Outlet Syndrome: A case report
- Infective endocarditis in adult congenital heart disease: A case report
- Takotsubo cardiomyopathy: A case report
- Cerebral Venous Thrombosis (CVT): A case report
- Hemophagocytic Lymphohistiocytosis in Dengue
- A prospective observational study on the prescription of Guideline Directed Medical Treatment (GDMT) for Heart Failure at Kauvery Heart City
- Guideline-Directed Medical Treatment (GDMT) of Heart Failure at Kauvery Hospitals: A clinical audit
- POST OPERATIVE Chapters 9 and 10 – Learning from Experience
- Chapter 14. How to keep updated in busy medical practice?
- Journal scan: A review of 15 recent papers of immediate clinical significance, harvested from major international journals
- சிந்தனையே சிறப்பு
- தோல்வியே வெற்றியின் பாதை
- Editorial
- Results of Mechanical Thrombectomy in acute stroke: A case study in a Tier 2 city in India
- A clinical audit—cost effective way of managing superficial chest wound infections post sternotomy
- Dental implants: Our experience and expertise
- A non-randomized retrospective study on the management of pediatric septic arthritis
- Analysis of femoral neck fracture in octogenarians and its management
- Airway management of a huge thyroid: A case report
- Cardiac Arrhythmias in the ER setting
- Effectiveness of tactile-spatial oriented approach based paediatric occupational therapy intervention for children with Infantile Hemiplegia
- Corporate citizenship in healthcare: Nurturing social responsibility
- Guillain-Barré syndrome: A case report
- POST OPERATIVE Chapters 11 and 12 – Learning from Experience
- Chapter 15. How to be rational in practice?
- Journal scan: Elsevier’s Medicine, Current Issue, Volume 52 Issue 6, June 2024, Seminar on Poisoning
- Recommended Readings
- இயற்கை சொல்லும் செய்தி
- Editorial
- Instructions for Authors
- A rare organism causing septic arthritis of hip joint
- ICD implant in 6 year old with Jervell and Lange-Nielsen (JLN) syndrome
- A clinical audit on Bariatric/Metabolic surgery
- Clinical audit on Nil per Oral (NPO)
- A non-randomized clinical study on heat stroke
- Stress cardiomyopathy with posterior reversible encephalopathy syndrome in Eclampsia
- Intro-Reversible Cerebral Vasoconstriction Syndrome (RCVS): An ultra-short case report
- A 2 am Tamponade: Critical call to action
- Immune Checkpoint Inhibitors, and in combination with JAK inhibitors: The modelling for the future
- Optimizing the patient journey in hypertrophic cardiomyopathy—Patient and clinician perspectives: Summary of CME from Medscape
- ER Intervention
- Diagnostic Images/Videos
- A randomized controlled trial: Different types of blinding
- Journal scan – June
- Journal scan – July
- Post-Operative Chapters 13, 14
- Chapter 16. How to enjoy medical practice?
- Driving business growth with 5S and lean strategies: A transformative session for corporations in the Trichy region
- Poem: 25 – வருடங்களாக காவேரி
- Editorial
- A Data Audit: Tool for Good Clinical Practice
- Ortho rehab audit at Kauvery Hospital, Trichy
- Endovascular Thrombectomy in young patient with a stroke – surgical procedure decompressive craniotomy
- Secondary HLH (Hemophagocytic Lymphohistiocytosis): An ultra-short case report
- Prone ventilation: A case series
- Dermatologic Emergencies: A case series
- Managing DKA at the ER
- Podcast – Managing DKA at the ER
- Insertion of tunneled hemodialysis catheter through the collateral vein adjacent to the thrombosed right jugular vein.
- Access failure with dysfunctional tunnelled haemodialysis catheter in the presence of exit-site infection
- Video – A multidisciplinary approach to preventing sudden cardiac death
- Dasatinib in pediatric Chronic Myeloid Leukemia: An overview
- Dyslipidemia management: Indian perspective
- Pharmacological stress testing: Assessing heart health without exercise
- Journal scan: A review of 15 Ethics with clinical significance, harvested from a major international journal
- Post-Operative Chapters 15 and 16
- Chapter 17. How to find time for the family
- Poem – உனக்காக நீ
- Editorial
- An audit: A silent disease-Osteoporosis
- An approach to antibiotic therapy: A primer for all specialties
- Audit on pediatric Cholesteatoma
- Clinical audit: ER to ICU transit time
- A case report on Multiple myeloma: Value of pre and post-treatment MRI
- Unrelated donor bone marrow transplantation in 3 year old with Acute Myeloid Leukemia
- Infective endocarditis: A case series
- A Retrospective observational study on Scrub typhus paediatric population in Kauvery Hospitals, Trichy
- Clinical Pharmacy Approach: To a patient on multiple anticonvulsants for “Difficult to control’’ seizure disorder
- An analysis of the Urea to Creatinine Ratio (UCR) in different cardiac surgeries
- Journal scan – 1
- Journal Scan – 2
- Post-Operative Chapters 17 and 18
- Chapter 18. How to be legally safe in medical practice?
- Poem – காவேரியின் மாரத்தான்
- Poem – ஆரோக்கியம் என்னுடையது
- Editorial
- Clinical audit on antibiogram
- Renal transplantation in marrow dysfunction: A case series
- Empowering lifesavers: Impact of BLS and PALS training for PICU and critical care nurses
- Myotonia congenita: A case series
- Utilization of Inj. Sovateltide: A novel injectable formulation
- Retroperitoneal sarcoma: A report of two cases
- Traumatic simultaneous bilateral femur and tibia shaft fracture in an 8-year-old male child: An unusual case report
- Echocardiography in the assessment of shock
- Plasma combats angioedema: A case report
- A case report and video presentation on a 9-year-old boy who underwent PAPVC
- Interventional Radiology: Large gastric varices
- Interventional Radiology: A case of active PV bleeding post-D and C day 12
- Diagnostic Images: Exencephaly
- A short case report on Hyperdontia (extra teeth)
- Post-Operative Chapters 19 and 20
- Chapter 19. How to deal with incurable disease?
- CII CFO Excellence award: A recognition of exceptional leadership
- Journal scan
- Poem – மறுக்காதே மறவாதே
- Editorial
- An audit: Microvascular Free Flaps
- DSME Programs – Lessons learned
- Surgical Reconstruction Of Acromio Clavicular Joint Dislocation Using Double Endobutton – A Case Report
- Complex Iliac Artery And Venous Reconstruction In Case Of Polytrauma – Case Report
- Basics of statistics- from of a clinician’s perspective
- A comprehensive review on Rabies: Clinical aspects and treatment
- Lateral Medullary Syndrome – Case Report
- Postpartum ischemic stroke – case report
- Proning Saves Lives
- Video – A challenging case of Recurrent craniopharyngioma with supra and infra tentorial cyst and hydrocephalus
- Event: Update on Atrial Fibrillation
- Investigating the Role of Activity-Based Configurational Developmental approach in Managing Mitochondrial Leukodystrophy in Children
- Post-Operative Chapters 21 and 22
- Chapter 20. How to deal with failure of treatment
- Journal scan: A review of 12 recent papers of immediate clinical significance, harvested from major international journals
- Poem – தன்னம்பிக்கையும் விடாமுயற்சியும்
- Extraordinary Edition of the Kauverian